MEDICARE: LISA WIDMER OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	119768	TX

General Provider Information

NPI Number	:	1184286007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA WIDMER OTR

Provider Business Mailing Address
First Line	:	317 WATER OAK
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76209-6517
Country	:	US
Telephone Number	:	469-237-6264
Fax Number	:

Provider Business Practice Location Address
First Line	:	6530 HAWKS CREEK CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-1163
Country	:	US
Telephone Number	:	888-332-9928
Fax Number	:	817-810-0240

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2019
Last Update Date	:	07/01/2019

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